Emergency Shelter Agreement

Emergency Shelter AGREEMENT

Note: This form should only be completed by mothers who have been referred and approved by a partner organization.

* Indicates required field

Mother's Name *

First

Last

Phone Number *

Email *

Previous Address *

Line 1

Line 2

City

State

Zip Code

Country

Names & Ages of Children *

What circumstances have caused you to need emergency shelter? *

Shelter From the Rain Emergency Shelter Requirements

I agree that the following are true:

1. I am a single mother/parent and I am not legally married.

2. I am currently homeless and have no other options for shelter.

3. I am pregnant or in custody of at least one of my children.

I agree that I meet all the requirements listed above: *

Yes No

Shelter From the Rain Emergency Shelter Terms & Guidelines

I agree to the following during my stay:

1. I understand that only myself and my children are permitted to stay in the room provided by Shelter From the Rain. If I violate this term, my stay can be terminated immediately.
2. I understand that I am not permitted to charge any other items to the room during my stay.
3. I understand that I am responsible for any damage done to the room during my stay.
4. I understand that I must check out of the hotel on the agreed date set by the hotel.
5. I understand that Shelter From the Rain is not responsible for any items lost, left or stolen during my time at the hotel.
6. I understand that I need to contact Shelter From the Rain at 912-232-5860 if I need to leave the hotel earlier than expected.
7. I understand that this is temporary shelter with a limited number of nights for shelter and I will work on a long-term solution while I am here.

Do you agree to the terms and guidelines of Shelter From the Rain's Emergency Shelter listed above: *

Yes No

Confirmation Check Box - Please Note: If any of the above information is not accurate, emergency shelter can be terminated. *

By checking this box, you confirm that the information provided above is accurate.

Submit